× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest

Osteoporosis

About

What is covered

This interactive flowchart covers NICE guidance on osteoporosis in people aged 18 and over, including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.

Updates

Updates to this interactive flowchart

27 April 2017 Osteoporosis (NICE quality standard 149) added.
28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations and one recommendation updated to correct reference to the WHO in relation to the FRAX tool.
20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing the risk of, preventing and treating osteoporotic fragility fractures in adults in an interactive flowchart

What is covered

This interactive flowchart covers NICE guidance on osteoporosis in people aged 18 and over, including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.

Updates

Updates to this interactive flowchart

27 April 2017 Osteoporosis (NICE quality standard 149) added.
28 February 2017 Structure revised, and summarised recommendations replaced with full recommendations and one recommendation updated to correct reference to the WHO in relation to the FRAX tool.
20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

Quality standards

Osteoporosis

These quality statements are taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statements

Assessment of fragility fracture risk

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults who have had a fragility fracture or use systemic glucocorticoids or have a history of falls have an assessment of their fracture risk.

Rationale

Risk assessment of adults who may be at increased risk of a fragility fracture enables healthcare professionals to estimate their fracture risk. This can be used to consider options for prevention and treatment, which will reduce the risk of future fractures.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have an assessment of their fracture risk.
Data source: Local data collection, for example, service specifications.
Process
a) Proportion of adults who have had a fragility fracture who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults who have had a fragility fracture.
Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis.
b) Proportion of adults who use systemic glucocorticoids who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults who use systemic glucocorticoids.
Data source: Local data collection, for example, local audit of patient records.
c) Proportion of adults aged 50 and over who have a history of falls who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults aged 50 and over who have a history of falls.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Incidence of fragility fractures.
Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and fracture liaison services) ensure that systems are in place for adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to have an assessment of their fracture risk.
Healthcare professionals (GPs, specialists, specialist nurses and fracture liaison practitioners) assess fracture risk, or confirm that assessment has taken place, in adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to estimate their risk of fracture and determine their treatment options.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have their fracture risk assessed.
Adults who have had a fragility fracture or falls in the past, or who are taking steroid treatment have their risk of fracture assessed. Fragility fractures happen in people with fragile bones that break easily, usually older people with osteoporosis. There are treatments available to help prevent fractures in people who are at increased risk. An assessment can help to decide if treatment will reduce the chance of having a fracture.

Source guidance

Osteoporosis: assessing the risk of fragility fracture (2012) NICE guideline CG146, recommendations 1.1 and 1.2

Definitions of terms used in this quality statement

Fragility fracture
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low energy') trauma. The World Health Organization has quantified this as forces equivalent to a fall from a standing height or less. Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones.
[NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, introduction]
Use of systemic glucocorticoids
Adults currently using systemic glucocorticoids, or who have been using systemic glucocorticoids for more than 3 months, at a dose of prednisolone of 5 mg daily or more (or equivalent doses of other glucocorticoids).
[Expert opinion and The University of Sheffield’s FRAX fracture risk assessment tool]
History of falls
One or more falls in the last 12 months. A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level. Adults aged 50 and over should have a fracture risk assessment if they have a history of falls.
[NICE’s clinical knowledge summary on falls – risk assessment and NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.1 and 1.2]
Assessment of fracture risk
An assessment of fracture risk should include estimating absolute fracture risk (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Either FRAX (without a bone mineral density [BMD] value if a DXA scan has not previously been undertaken) or QFracture should be used within their allowed age ranges. Above the upper age limits defined by the tools, consider people to be at high risk. Measure BMD to assess fracture risk in people aged under 40 years.
[Adapted from NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.3, 1.4 and 1.9]

Starting drug treatment

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.

Rationale

Fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life and sometimes to decreased life expectancy. Taking drug treatment to improve bone density reduces the chance of future fractures and related problems.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local protocols.
Process
Proportion of adults at high risk of fragility fracture receiving drug treatment to reduce fracture risk.
Numerator – the number in the denominator who receive drug treatment to reduce fracture risk.
Denominator – the number of adults at high risk of fragility fracture.
Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent.
Outcomes
a) Incidence of fragility fractures.
Data source: Local data collection, for example, local audit of patient records.
b) Hospital admission rates for fragility fractures.
Data source: Local data collection, for example, Hospital episode statistics from NHS Digital.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults at high risk of fragility fracture to be offered drug treatment to reduce fracture risk.
Healthcare professionals (GPs, specialists and specialist nurses) are aware of when to prescribe drug treatments to reduce fracture risk, and offer them to adults at high risk of fragility fracture.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Adults with a high chance of fragility fracture are offered medicine to help strengthen their bones and prevent fractures.

Source guidance

Definitions of terms used in this quality statement

At high risk of fragility fracture
Women with a prior fragility fracture (particularly hip or vertebral fracture) and men and women with a 10-year probability of a major osteoporotic fracture derived from FRAX, above the upper assessment threshold, should be considered for treatment (see table 1). Men and women with a 10-year probability between the upper and lower assessment threshold should be referred for bone mineral density measurement and their fracture probability reassessed. If their 10-year fracture probability is above the intervention threshold after reassessment (see table 1), treatment should be offered.
Table 1. Lower and upper assessment thresholds and intervention thresholds for major osteoporotic fracture probability based on fracture probabilities derived from FRAX (BMI set to 25 kg/m2)
10-year probability of a major osteoporotic fracture (%)
Age (years)
Lower assessment threshold
Upper assessment threshold
Intervention threshold
40
2.6
7.1
5.9
45
2.7
7.2
6.0
50
3.4
8.6
7.2
55
4.5
11
9.4
60
5.9
14
12
65
8.4
19
16
≥70
11
24
20
Reproduced with permission from McCloskey et al. (2015) FRAX-based assessment and intervention thresholds – an exploration of thresholds in women aged 50 years and older in the UK. Osteoporosis International 26 (8), 2091–9
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 11, recommendation 7]
Drug treatment to reduce fracture risk
Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy).
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 6]

Equality and diversity considerations

Guidance on treatment to prevent fragility fractures has been focused on treating post-menopausal women, because of their increased risk. Clinicians should ensure that other populations who might benefit from recommended treatments are also considered.  

Adverse effects and adherence to treatment

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.

Rationale

People prescribed drugs to prevent fragility fractures sometimes stop taking them because of adverse effects. Adherence to treatment, including taking their medicine by the recommended method, is needed to ensure that fracture risk is reduced effectively. Checking how well a person is managing their treatment at each medication review means that any problems can be discussed and their treatment adjusted if needed, which will improve adherence and quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.
Data source: Local data collection, for example, service specifications.
Process
Proportion of medication reviews for adults prescribed drug treatment to reduce fracture risk that include a record of adverse effects and adherence to treatment.
Numerator – the number in the denominator that include a record of adverse effects and adherence to treatment.
Denominator – the number of medication reviews for adults prescribed drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Adults adhering to drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local audit of patient records.
b) Incidence of fragility fracture.
Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and pharmacies) ensure that systems are in place for adults prescribed drug treatment to reduce fracture risk to be asked if they have had any adverse effects and about adherence to treatment at each medication review.
Healthcare professionals (GPs, specialists, specialist nurses and pharmacists) carry out medication reviews with adults prescribed drug treatments to reduce fracture risk. At the reviews, they ask if the person has had any adverse effects and if they are taking their medicine by the recommended method and as prescribed. If any problems are raised, these should be discussed and treatment adjusted if needed, which may involve input from a specialist.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults prescribed drug treatment to reduce fracture risk are asked if they have had any adverse effects and about adherence to treatment at each medication review.
Adults taking medicine to help prevent fractures have regular medicine reviews with their doctor to check if they are having any side effects, such as heartburn or reflux, and that they are taking the medicine correctly. The review gives the chance for any problems to be discussed and treatment can be adjusted if needed to help with side effects.

Source guidance

Definitions of terms used in this quality statement

Drug treatment to reduce fracture risk
Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy).
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 6]
Medication review
The review should include:
  • asking about adverse effects, including upper gastrointestinal adverse effects (such as dyspepsia or reflux), symptoms of atypical fracture (including new onset hip, groin, or thigh pain), and dental problems
  • asking about adherence to treatment, including following the recommended method of taking the treatment
  • discussing alternative treatment options if adverse effects are unacceptable or the person has difficulty adhering to treatment.
[Expert opinion and NICE’s clinical knowledge summary on osteoporosis – prevention of fragility fractures]

Long-term follow-up

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults having long-term bisphosphonate therapy have a review of the need for continuing treatment.

Rationale

The optimal duration of bisphosphonate therapy is unclear and there are possible adverse effects of long-term treatment. A medication review for people having long-term bisphosphonate therapy gives the opportunity to consider whether continuing treatment is the best option, or if treatment should be changed or stopped. The response to treatment may also be evaluated to help determine whether to continue treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults taking zoledronic acid for 3 years have a review of the need for continuing treatment.
Data source: Local data collection, for example, local protocols.
b) Evidence of local arrangements to ensure that adults taking alendronate, ibandronate or risedronate for 5 years have a review of the need for continuing treatment.
Data source: Local data collection, for example, local protocols.
Process
a) Proportion of adults taking zoledronic acid for 3 years who have a review of the need for continuing treatment.
Numerator – the number in the denominator who have a review of the need for continuing treatment.
Denominator – the number of adults taking zoledronic acid for 3 years.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults taking alendronate, ibandronate or risedronate for 5 years who have a review of the need for continuing treatment.
Numerator – the number in the denominator who have a review of the need for continuing treatment.
Denominator – the number of adults taking alendronate, ibandronate or risedronate for 5 years.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Patient satisfaction with long-term bisphosphonate therapy.
Data source: Local data collection, for example, patient surveys.
b) Health-related quality of life for adults having long-term bisphosphonate therapy.
Data source: Local data collection, for example, patient surveys.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and pharmacies) ensure that systems are in place for adults having long-term bisphosphonate therapy to have a review of the need for continuing treatment.
Healthcare professionals (GPs, specialists, specialist nurses and pharmacists) offer adults having long-term bisphosphonate therapy a medication review to discuss the risks and benefits of continuing treatment and assess their response to treatment, if needed.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults having long-term bisphosphonate therapy have a review of the need for continuing treatment.
Adults taking a type of medicine called a bisphosphonate over a long time to help prevent fractures have a review to discuss the risks and benefits of continuing with the treatment. They might also have a scan to check whether their bone strength has improved to help decide whether to continue treatment.

Source guidance

Definitions of terms used in this quality statement

Long-term bisphosphonate therapy
Adults who have been taking zoledronic acid for 3 years or alendronate, ibandronate or risedronate for 5 years should have a review of the need for continuing treatment.
[National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 7, recommendation 6]
Review of the need for continuing treatment
Continuation of treatment is recommended for people with any of the following risk factors:
  • age over 75 years
  • previous hip or vertebral fracture
  • one or more low trauma fractures during treatment (after poor adherence to treatment, for example less than 80% of treatment has been taken, and causes of secondary osteoporosis have been excluded)
  • current treatment with oral glucocorticoids of 7.5 mg or more prednisolone/day or equivalent.
For people without risk factors, arrange a dual-energy X-ray absorptiometry (DXA) scan and consider:
  • Continuing treatment if the T-score is less than -2.5, and reassessing fracture risk and bone mineral density (BMD) every 3 to 5 years.
  • Stopping treatment if the T-score is greater than -2.5, and reassessing their fracture risk and BMD after 2 years.
[Adapted from NICE’s clinical knowledge summary on osteoporosis – prevention of fragility fractures and National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 7, recommendation 4]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Causes of secondary osteoporosis include:
  • endocrine
    • hypogonadism in either sex including
      • untreated premature menopause and
      • treatment with aromatase inhibitors or androgen deprivation therapy
    • hyperthyroidism
    • hyperparathyroidism
    • hyperprolactinaemia
    • Cushing's disease
    • diabetes
  • gastrointestinal
    • coeliac disease
    • inflammatory bowel disease
    • chronic liver disease
    • chronic pancreatitis
    • other causes of malabsorption
  • rheumatological
    • rheumatoid arthritis
    • other inflammatory arthropathies
  • haematological
    • multiple myeloma
    • haemoglobinopathies
    • systemic mastocytosis
  • respiratory
    • cystic fibrosis
    • chronic obstructive pulmonary disease
  • metabolic (homocystinuria)
  • chronic renal disease and immobility (due for example to neurological injury or disease).

Glossary

bone mineral density
dual-energy X-ray absorptiometry
the level of risk at which an intervention is recommended; people whose risk is in the region from just below to just above the threshold may be reclassified if BMD is added to assessment (it was out of the scope of the osteoporosis: fragility fracture risk clinical guideline to recommend intervention thresholds; healthcare professionals should follow local protocols or other national guidelines for advice on intervention thresholds)
standard deviations

Paths in this pathway

Pathway created: August 2012 Last updated: April 2017

© NICE 2017

Recently viewed